Shoshana Walter (2:56)

Thanks so much, Emily, for having me.

Emily Dufton (2:58)

So you first started working on this project a number of years ago. How did you find this story and what attracted you to this work?

Shoshana Walter (3:06)

Well, about eight years ago, I was a reporter at Reveal when I kind of just stumbled across this DRE drug rehab program that was being used by courts throughout Oklahoma and Arkansas and Missouri. Basically, judges were sending people to this long term rehab program in lieu of incarceration, which sounded really great in theory. But when I started to do a little bit of digging into this program, I learned that it had been founded by a former poultry industry executive and that it was sending people to work without pay at for profit chicken processing plants where they were making chicken products for KFC and Popeyes and Walmart and petsmart and Rachael Ray Nutrish. And they weren't receiving any compensation. They were working long hours in these really dangerous jobs leading often to injury. And this was considered their sole form of treatment in this program. And, you know, that discovery led to a series of stories. It led to a podcast series that I didn't reveal. But in the meantime, I was just kind of shocked by this. I think over the course of the opioid epidemic, our country has undergone this kind of cultural shift of viewing addiction and accepting addiction as a disease that's worthy of compassion and medical care and treatment. And so I was just very confused that indentured labor would be considered a form of treatment in this day and age in the United States. And it made me want to understand how common that is and why that's the case, that forced labor would be considered treatment. And also, if that is part of our treatment system, then what does the rest of our treatment landscape look like? And is it working and helping people the way it was intended?

Emily Dufton (5:11)

Much of this industry remains really murky. It's almost like hiding in plain sight. Was it difficult to find people who wanted to talk to you about this?

Shoshana Walter (5:21)

So actually, it wasn't actually that difficult to find people to talk to about their experiences in the rehab industry. In part, I think, because of this culture that exists in the recovery community of sharing your personal stories, sharing your stories of adversity and how you overcome obstacles and challenges, and, you know, pretty much every Person that I interviewed in and out of recovery had a story to share about rehab. It is a very common experience to go to a rehab program, to go to multiple rehab programs, and to experience poor treatment in various ways. So I think when I was first starting out on the book to really get a lay of the land, I interviewed hundreds of people about their experiences. I think what became more challenging was when I was zeroing in on specific programs. And you know, there was a program in the book that I focus on that required participants to perform unpaid labor. There was another program I focused on in the book that was overmedicating patients to the point of impairment. And then another program in the book that was actually investigated and shut down by the Drug Enforcement Administration. And, you know, finding people within those programs who worked at those programs to help me verify the claims that I was hearing about them was, I would say, the more difficult part of the book. Just kind of the investigative efforts that went into it. It took many years to really uncover the facts in a lot of these cases.

Emily Dufton (7:04)

Wow, that's a huge commitment to this story. It's really impressive. You end up zeroing in on four individuals that the book follows. There's Chris Coon, April Lee, Larry ley and Wendy McIntyre. And they're great people to focus on because they're all so different. They're scattered across the country, they're involved in many different kinds of rehabilitation programs and they experience really varied outcomes. Can you describe these four people that you profile and what drew you to them?

Shoshana Walter (7:38)

Absolutely. So April Lee and Chris Coon are both people who went through the treatment industry. Chris is a middle class white guy from Louisiana who went to an insurance funded program and then to a court ordered program that required him to work without pay. April is in a little bit of a different situation. She grew up in a very poor black community. She had three kids at the time that she was going through her addiction. And her story really shows the barriers and gaps in our treatment system that exist for many people across this country who still have an extremely hard time accessing treatment and often face punishment as a result of it. Larry Ley was one of the first Suboxone prescribers in the United States. And because of the way he was prescribing, he was investigated by the Drug Enforcement Administration, which had very severe consequences for him and all of his patients. And Wendy McIntyre is a grandmother from Los Angeles who became something of a activist vigilante, obsessively rooting out corruption in the for profit treatment industry after her own son died. Of an overdose at a sober living home. So, you know, each of these people represent very different aspects of our treatment system. And that was really important to me in pursuing this book that I be able to paint a really comprehensive picture of what this system look looks like and in a vivid sense really paint a picture for readers of why it's not working and how it's not working through the experiences of these four individuals.

Emily Dufton (9:33)

You're also a character in the book. Shoshana makes many appearances, which I loved. And you describe your experiences with these four individuals. You're riding with them in cars, you're visiting them, you're spending hours on the phone. What was it like developing these really close years long relationships with your subjects and then writing about it? And as a follow up, how do you think they felt about you?

Shoshana Walter (10:00)

Well, it's not an easy ask to ask someone to open up their lives to me for years at a time. And I think when I first approached all of these individuals, none of us knew how long we were really in for. We've definitely all known each other now for many years. Larry Leigh passed away a couple years ago, so unfortunately he was never able to see the book. But yeah, I would say each of these individuals really opened themselves up in very vulnerable ways. April, during the course of her active addiction, she kept these journals and diaries and wrote, wrote poems and she allowed me to read all of it so that I could really see through her words what that experience was like for her in that moment. You know, she's now in recovery, but she took me back to Kensington, which is the largest open air drug market on the east coast, and where she was unhoused for a while. And you know, we walked around and, you know, and I got to see where April used to sleep on a grassy plot outside the community center. You know, the bodega where she would buy the cherry flavored honey bun every morning. Many of the houses that she squatted in with other people who kind of looked up to her and called her mom because she was like a mom figure on the street. So yeah, over the course of these years I really got to know these individuals. And it was also difficult though, because many of our relationships started in earnest during the early, the early months and years of the pandemic. So it took a long time before I was actually able to visit Wende in person, for example. But I remember, you know, initially when I first approached Wende, I just viewed, I viewed her as kind of like a subject matter expert because she's been quoted in News articles in California for years about problems in the treatment industry. She's been calling for better oversight for years. But the very first phone conversation we ever had, I knew there was so much more to her story that had to be told because those quotes just did not encompass who Wende fully is. I learned she does these comprehensive investigations. She's so zealous in her pursuit of justice that several rehab programs have filed restraining orders against her. She had been arrested for violating a restraining order. And I just wanted to understand the urgency behind her actions and what led her to pursue for profit treatment companies in this way. And when I finally got to meet Wende in person, you know, I walked into her house and into her living room and the floor was like carpeted in boxes and boxes of her investigative records, all of her interviews, all of the documents from within the rehab that she had accumulated, photographs from her surveillance, her surveillance operations. So, you know, I just was amazed by all of Wendy's efforts. I wanted to understand, you know, how she had become the way she is. And, you know, I think so many people had. Wendy was used to many people dismissing her as crazy, as mentally ill, as, you know, a grieving mom who took it too far. And what I could tell from all of those investigations and all of her efforts was that there was a very real problem that Wende was trying to address. And this particular rehab that I focus on in the story in the book, you know, people were dying in this rehab and Wendy was treating that with the urgency it really deserved.

Emily Dufton (14:20)

Didn't she give herself a nickname like an Erin Brockovich portmanteau with her name or someone gave her that nickname? Right.

Shoshana Walter (14:28)

She, she early on, you know, she founded this nonprofit called Jared's Law after her son, where she operates this 24 hour hotline for people to call for help getting out of abusive facilities. And early on she printed business cards that said Wendy Brockabich McIntyre.

Emily Dufton (14:46)

That's it. That's it. I thought that was just brilliant. I thought that was.

Shoshana Walter (14:52)

Definitely speaks to who Wende is for sure.

Emily Dufton (14:54)

It definitely does. So I mean, some of the outcomes for these individuals are semi positive. April, who you described before, she was the person I really found myself rooting for the most, I think, because I love Philly so much and she's a Philly girl, so she's immediately endeared to me. But she, but she also really pulls herself through and I was impressed by her sheer force of will and her empathy for others. But it's clear in your book that April is the exception and not the rule. Instead, most rehabs fail. Can you tell us a bit about the programs you covered that did not seem to help their clients very well?

Shoshana Walter (15:36)

Yeah, absolutely. I mean, I think a big feature in the book are these 30 day insurance funded programs that really proliferated with the passage of the Affordable Care Act. And what we now know about those programs is that they oftentimes fuel relapse. You know, someone who completes a 30 day program is much more likely to overdose and die in the year following treatment than someone who failed to complete that program at all. And so, you know, now a lot of treatment facility owners, even those who are really frustrated by this insurance imposed limitation, view relapse as part of their business model. You know, I interviewed the owner of that treatment facility that Wendy investigated and he referred to it as a cycler. People come in, they complete the program, they quote, unquote, graduate, they leave, and then they relapse and come right back. And you know, his aftercare, quote, unquote, aftercare program, something that a lot of treatment facilities have, basically consisted of employees calling former participants, finding out if they relapsed and if they had, especially if they had high paying insurance, re enroll them in the program. So there's a way that we are funding these short bursts of treatment in the country that are not serving people well. These are actually fueling relapse and addiction rates. And then, you know, you have Chris, who went to this court ordered program. So many people still are funneled into addiction treatment through the criminal justice system. But in many of those programs that are utilized by courts, they're punishment based. They rely on behavior modification techniques that in some, in some cases can be abusive, particularly for people with histories of trauma. And they often require uncompensated labor. What I've been seeing for the past few years is that these programs are really taking advantage of the desire for a cheap labor source. And so some of these rehab facilities, like the one I focus on in the book, are really operating like unpaid temporary labor forces like staffing agencies. And Chris, when he got to the program called the Senecor foundation, he quickly learned that he would be working up to 80 hours per week without pay. His only compensation was a pack of cigarettes per week. And despite all this, all these promises the program had made about the services they were going to provide, he rarely had time even for counseling. I spoke with his counselor who told me that she would poke her head into his room after a long day of work, say, how you doing? He'd say, fine. And Then she'd mark that off as a counseling session.

Emily Dufton (18:38)

So bill it and bill Medicaid for it, I'm sure.

Shoshana Walter (18:41)

I don't know if that was the case in his situation, but definitely there were participants at that program who were Medicaid funded. So, yeah, I mean, there is a lot of profiteering in this industry. It tends to be very short bursts of treatment there that don't work for many people, especially people like April who come from situations where they have very few resources to begin with. April did actually try a 30 day program, but upon leaving such a common story, she relapsed and that just made her already unstable situation worse. And for someone like April without any resources to draw from, it could be so much more difficult, difficult to enter recovery than someone like Chris who has family support, who has financial support, who has connections to potential job or educational opportunities that someone like April doesn't have. And I think that is another big takeaway that I had from my reporting of this book. I went into it thinking it was going to be focused entirely on treatment. But I think what I have, what I found is that in some ways it's what happens after treatment that is more important than the treatment itself. You know, what kind of resources do people have to draw from in order to actually enter and sustain long term recovery?

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Emily Dufton (21:20)

So there's a lot of variety in the treatment marketplace, but there's not a lot of regulation. Can you discuss the legal and regulatory framework that these programs exist in? Like, what are they even classified as? Are they healthcare providers, social services, like something in between? What are they?

Shoshana Walter (21:39)

Yeah, I mean, basically, pretty much almost every treatment program is operated often separately from our mainstream medical system. So you have clinics or facilities that are offering addiction treatment, medications like Suboxone, methadone, buprenorphine. You have these insurance funded programs that may start with detox and last 30, 60 days that are typically licensed differently in each state. And then you have often these long term recovery programs which are often faith based, they're often totally unlicensed, not subject to licensure in many states, and often require this uncompensated work. And these are typically the programs that cater to people without insurance, without financial resources to afford a more private program. And I would say, you know, each state regulates rehab differently, but there are a lot of loopholes to oversight. So in California, which is one of the rehab destinations for the country, outpatient programs are not required to be licensed. It's completely voluntary. And sober living homes are also not subject to licensure. And so when a treatment program, you know, is when a complaint is filed against a treatment program and a program is investigated and the state makes the unusual attempt to revoke that program's license or file disciplinary action in some way, in a lot of cases, treatment companies can simply get around oversight altogether by classifying their program as an outpatient program and then housing people in their sober living home. And so I would say, you know, each state is completely different. It's always disconnected, almost always disconnected from our medical system. And, you know, oversight is incredibly poor. It's very easy for a treatment program that is mistreating patients to get away with that mistreatment, even in cases where they are licensed and regulators come in. You know, I saw with Senecor, you know, many, many times, you know, there had been more than a decade of complaints about unpaid labor at Senacor, about, about really poor conditions like roaches and rats and black mold, about people being mistreated in the program, subject to harassment or abuse. And oftentimes what happens with state regulators is they offer treatment programs the opportunity to submit what is called, oftentimes a corrective action plan. The facility submits that. It's basically on the honor system whether or not they comply with what they've promised to do. And that's it. And so, you know, facilities remain open despite longstanding, documented histories of mistreatment.

Emily Dufton (25:00)

And yet these programs are also making a lot of money right now. You had mentioned the passage of Obamacare. You talked a little bit about how these programs provide cheap labor. Can you discuss a bit more of the economic landscape that these rehabs exist in?

Shoshana Walter (25:18)

Yeah, I mean, the Affordable Care act really made a humongous difference in the number of people who even have access to treatment in the United States. And I would say, like, largely, that's a very good thing. You know, it expanded treatment, access to millions more Americans. And treatment can be really beneficial for, for certain people. So I don't want to discount that in any way. But, you know, the way that insurance companies tend to fund treatment is in very short, limited bursts. Sometimes there's even barriers to getting access to treatment through insurance companies. But when insurance companies do approve treatment, it tends to be for the short term. And that quickly becomes very expensive when someone attends treatment, relapses, and then has to go back into the system again. What I found in reading studies and talking to researchers is that long term treatment and support is incredibly important for people, particularly people who are struggling with opioid addiction. You know, addiction treatment medications, which are still hard to come by, are incredibly important for people to be able to access. And once they're on these medications, helping people access what's known in research circles as recovery capital. You know, this mixture of external and internal resources that people need to draw from in order to enter and sustain recovery is also incredibly instrumental. So, you know, recovery capital can include community and social support. It also includes, you know, housing, financial stability, food, transportation, you know, all the basic necessities that most of us would consider we need in order to live and survive and thrive. You know, people who struggle with addiction need these things too. And I think the problem in the United States is that the longer someone remains in addiction, the more marginalized they become, the more punished they are. And the consequences of addiction can make it that much harder to accrue recovery capital and to overcome those barriers. So in a way, the consequences of addiction can become as much a barrier to recovery as the addiction itself. And training programs are often not helping provide people with the opportunities to accrue that recovery capital.

Emily Dufton (27:55)

I'd like to talk more about that. You know, some of the experiences that the people you profile go through are really harrowing. Right. Your Senate corps reporting was also in the podcast. The whole thing really is just such a horrific scene, but it's far from alone. Right from synanon in the 1950s, which you discuss to senecor and tough love programs today. It feels like punishment has always been a kind of hallmark of addiction treatment. You write about people being forced to labor in horrible conditions for, like, a pack of cigarettes, but also about getting brainwashed and yelled at and forced to kneel in corners for hours. And these are things that don't seem, from maybe a proper distance to be terribly useful in combating addiction. And yet these programs persist, and as you point out, they're making a lot of money. So reading your book, I really began to wonder why that was. Why. Why do you think punishment is such a big part of addiction treatment?

Shoshana Walter (28:59)

I think the most enduring belief about addiction that remains persistent to this day is this idea of addiction as a moral failing, as, you know, someone who's addicted even could have a mental problem. You know, there was a point in time where researchers believed that addicted people were psychopaths and that the only way to really treat them was to contain them, to contain this problem, to prevent it from spreading, to prevent addicted people from infecting other people with this problem. And I just think that belief system continues, and I think criminalization is often our country's solution to complicated social problems. What we've been talking about, I think, speaks to the fact that, you know, addicted people need more than just addiction treatment. You know, they need. They need access to opportunities that maybe our medical system cannot provide, our treatment system cannot provide. So this makes addiction more complicated. It means that there's no magic, magical solution or cure for addiction. And so an easy answer to a complicated problem is simply punishment. You know? Right.

Emily Dufton (30:37)

The podcaster Katie Herzog just wrote a book about using naltrexone to stop her addictive drinking. And when I interviewed her last month, she said something that just really stayed with me. She said, rehab programs make patients suffer because the patient caused suffering to others when they were in their addiction. So rehab is a way of punishing them to make them pay for their transgressions. And reading rehab, I really thought there might be something to that. What do you think about Katie's definition of treatment being something, you know, to cause suffering to the patient because they hurt other people?

Shoshana Walter (31:15)

I mean, I definitely. That really resonates with me. I think that's true. I think also punishment is viewed as a way to get people to hit their rock bottom, you know, to push people to their absolute lowest, to their breaking point, so that suddenly they will. They would be willing to accept help that is being offered in the treatment program. So I think it is kind of all of these things. You know, it's. Yeah. Treatment providers view people with addiction as needing to be punished, you know, for their transgressions, maybe be humbled is something I've heard many, many times. And also, you know, they view this cruelty as a way to force people into their rock bottom, which is often viewed in the recovery community as the only way that someone is going to change. But I think we know now from research that's not true. You know, people don't need to hit their rock bottom. The rock bottom is always shifting. It could always get worse. And in the age of fentanyl and some of the other illicit drugs that we're seeing on the market, hitting rock bottom can be incredibly dangerous. It can be deadly. So I think that there's a way to motivate people to change that doesn't involve cruelty. It's just a potentially more complicated way of viewing things.

Emily Dufton (32:45)

Right. Can you update us on the four people you follow? I know you said not everyone survives. We lost Larry Leigh a couple years ago. How is everyone else doing?

Shoshana Walter (32:54)

Yeah, I mean, you know, at the end of the book, Wendy seems a bit resigned. You know, she's been arrested and is feeling like maybe she needs to hang up her hat. But I can say that Wendy has not hung up her hat.

Emily Dufton (33:10)

All right. Very much.

Shoshana Walter (33:12)

Still advocating for patients in California and pushing for legislation. Chris is doing really well. He lives in Texas now. He's married. He has a couple of kids and is still on Suboxone. And April is also doing really well. She just founded her own nonprofit organization, which will be helping mothers struggling with addiction like April once had, and in particular, women who may be involved in the child welfare system. You know, we didn't talk too much about April's story, but because of her addiction, she, you know, lost custody of her three kids. It took her many years to get them back. And so she's really deeply, intimately familiar with what that experience feels like for mothers and for families. And so through her nonprofit, she's helping to help more people like her.

Emily Dufton (34:07)

Oh, that's incredible. That's great to hear. So your previous podcast launched a series of investigations, which is amazing. How has the response to this book been? Are you going to prompt more series of investigations? Are you going to clean up this. This broken industry? Shoshana, someone has to do it. Is it you? Oh, boy.

Shoshana Walter (34:29)

You know, I definitely, in response to some stories that I've done, there has been. There have been investigations, and, you know, criminal investigations, congressional investigations, new laws, more Often than not, however, I think that my stories don't lead to lasting change. But I do think I really believe in the power of stories to spread awareness. And I think that stories like the one you mentioned and books like this can be part of a long term process of change. So I am hopeful that maybe eventually some of the messages in this book will reach the people who they need to reach. And I've been really heartened to see how many people within the treatment industry are reading this book, calling for change within the industry. I know that a number of lawmakers have the book and are reading it. So, yeah, I don't think I'll be cleaning up this town, at least not alone.

Emily Dufton (35:33)

But you're starting to sweep. The broom is in your hand. That's great. So you plan on continuing to write about the rehab industry then?

Shoshana Walter (35:41)

Yeah, well, along these lines, you know, the past couple of years I've been pursuing stories that really stemmed from the reporting that I did for this book. Reporting that often couldn't, you know, I just couldn't make it in. Reporting that just didn't fit into the book. I've been really focused on women getting drug tested when they go into the hospital to give birth and what the consequences of those drug tests and what those drug tests lead to in terms of consequences for families. And I'm continuing that reporting now. I feel like my unofficial beat for the past few years has been kind of the unintended consequences of our country's drug laws and how harmful some of those consequences can be. So I'm continuing that reporting. And then after that I might take.

Emily Dufton (36:44)

A little break from understandable but good. I'm glad to hear you're sticking with it. So I know that this is. There's no easy response to this, but if you could wave a magic wand and change one thing about the rehab industry, what would it be?

Shoshana Walter (36:58)

You know, I think. I think one of the biggest problems in our treatment industry right now is the fact that insurance companies are funding these very short bursts of treatment that aren't helping people in the long run. So I definitely think that increasing the length of treatment that is covered would help a lot more people. Breaking down barriers to certain treatment would also help a lot of people. So making it easier for people to access addiction treatment medications would be super instrumental. Um, and, you know, I think that we've been talking about recovery capital. You know, I think that needs to be that. I think recovery capital is just a huge missing part of our treatment system that is currently really not being addressed. And I think that if more, if more of our treatment system really looked at that as an important piece of the recovery and treatment process, a lot more people would be helped by the system that we have.

Emily Dufton (38:08)

Right. Right. Well, may that want be waived and may that come to pass. Right. May this all happen. And your book will be an instrumental part in at least initiating some really important conversations. So I can't thank you enough for writing it. It's a huge contribution to understanding this field and I really enjoyed it. And I really encourage all of our listeners to run out and buy not one, but maybe several copies for families and friends, for everyone. So now for our traditional final question. I know you already said you're going to keep writing about rehab, but I'm going to ask it to you anyway. What are you working on now and what can we expect to talk about with you next?

Shoshana Walter (38:43)

Well, I'm not currently working on a new book. I'm not sure when that will happen or if it will happen. But at the Marshall Project, like I mentioned before, I've been focused on stories about hospital drug testing at childbirth. In particular, my recent stories have focused on how many of the tests that hospitals are using have extremely high false positive rates and are very easy to misinterpret. So the policies that existed in the crack epidemic that really expanded during the opioid epidemic, and they've expanded to the extent that they are now affecting so many more women and people than they ever used to. And so women have been reported to child welfare authorities for eating poppy seed bagels that caused positive tests for opiates, for taking high blood pressure medication which can cause false positives for meth, even for the fentanyl that they received in their epidurals that can cause a positive test for them and for their babies. And so women are getting reported to authorities over these positive tests, and sometimes child welfare authorities are removing newborns from their care. And so I'm still working on that topic now. I'm looking at kind of the criminal consequences of those positive tests in an era of increased pregnancy, surveillance and criminalization. And that'll be coming out sometime in the next few months. And then after that, I don't know. We'll see.

Emily Dufton (40:29)

Well, thank you. Thank you for telling these really crucial and important stories and thank you for taking the time to talk with us today. I really enjoyed it.

Shoshana Walter (40:37)

Oh, thank you so much for having me, Emily. I appreciate it.